Inspection Reports for Franklin Wellness and Rehabilitation Center
TN, 37064
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
30% worse than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
57 residents
Based on a June 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jun 9, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding inaccurate resident assessments, medication administration errors, inadequate supervision leading to resident elopement, and medication storage and administration safety concerns.
Complaint Details
The complaint investigation included issues of inaccurate resident assessment coding, medication administration errors including giving incorrect doses and leaving medications unattended, and inadequate supervision leading to resident elopement on two occasions (4/27/2024 and 5/5/2024) which resulted in Immediate Jeopardy. The facility implemented corrective actions including 1:1 supervision, door locking mechanism repairs, staff education, elopement drills, and resident relocation to a secure unit.
Findings
The facility failed to accurately assess antipsychotic medication use for a resident, failed to follow physician's orders for medication administration, failed to provide adequate supervision to prevent resident elopement resulting in immediate jeopardy, and failed to ensure medications were safely stored and administered without leaving them unattended in residents' rooms.
Deficiencies (4)
Failed to accurately assess the use of antipsychotic medication for 1 of 6 residents reviewed.
Failed to follow physician's orders and administer medications according to professional standards for 1 of 6 residents reviewed.
Failed to ensure adequate supervision to prevent elopement for 1 of 3 residents reviewed, resulting in Immediate Jeopardy.
Failed to ensure medications were stored and administered safely when medications were left unattended in resident's room during medication administration for 1 of 6 residents reviewed.
Report Facts
Residents reviewed for antipsychotic medication assessment: 6
Residents reviewed for medication administration: 6
Residents reviewed for supervision and accident hazards: 3
Residents reviewed for medication storage and administration safety: 6
Dates of Resident #10 elopements: 4/27/2024 and 5/5/2024
Resident #10 1:1 supervision duration: 3
Medication doses signed off incorrectly: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Director of Clinical Services | Confirmed Resident #31 received antipsychotic medications not accurately coded; confirmed medication administration errors for Resident #15; notified of Immediate Jeopardy related to Resident #10 elopements. | |
| Administrator | Notified of Immediate Jeopardy related to Resident #10 elopements; participated in corrective action planning and QAPI meetings. | |
| Previous Assistant Director of Nursing Q | Assistant Director of Nursing | Reported medication left unattended for Resident #5; signed statement regarding complaint. |
| Receptionist S | Witnessed Resident #10 elopement on 4/27/2024; provided statement about incident. | |
| Licensed Practical Nurse T | Licensed Practical Nurse | Responded to door alarm and recovered Resident #10 on 5/5/2024; provided witness statement. |
| Certified Nursing Assistant R | Certified Nursing Assistant | Witnessed Resident #10 elopement on 4/27/2024; provided statement. |
| Housekeeper BB | Assisted in securing Resident #10 during elopement on 4/27/2024; provided statement. | |
| Registered Nurse A | Registered Nurse | Left medications unattended in Resident #5's room; involved in medication administration complaint. |
| Director of Nursing | Director of Nursing | Confirmed proper medication administration procedures and policies. |
| Medical Director | Participated in QAPI meetings related to Resident #10 elopements. |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 5
Date: Jun 9, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to maintain residents' nutritional status, failure to provide safe dialysis care, medication administration errors, food safety violations, and infection control issues.
Complaint Details
The visit was complaint-related due to allegations of failure to maintain nutritional status, safe dialysis care, medication safety, food safety, and infection control. Immediate jeopardy was identified related to nutritional deficiencies and severe weight loss in multiple residents.
Findings
The facility failed to ensure residents maintained acceptable nutritional status, failed to obtain and monitor weights, and implement nutritional interventions, resulting in immediate jeopardy for several residents. The facility also failed to provide safe dialysis care, failed to properly store and administer medications, failed to maintain food safety standards including expired emergency food supplies, and failed to implement proper infection prevention and control measures for residents on isolation precautions.
Deficiencies (5)
Failure to ensure residents maintained acceptable nutritional status and implement interventions, resulting in immediate jeopardy for residents #17, #32, and #52 due to severe weight loss.
Failure to provide safe, appropriate dialysis care and maintain communication with dialysis center for residents #19 and #42.
Failure to ensure medications were stored and administered safely when medications were left unattended in resident #5's room during medication administration.
Failure to ensure food was stored, handled, prepared, and served under sanitary conditions, including incomplete food temperature logs, dish washer temperature and sanitizer checks, and expired foods found in emergency food supply.
Failure to provide a safe, sanitary, and comfortable environment to prevent transmission of infections for resident #258 on Transmission Based Precautions, including failure to wear proper PPE and improper handling of food trays.
Report Facts
Residents with severe weight loss: 7
Weight loss percentage: 25.9
Weight loss percentage: 27.2
Weight loss percentage: 9.41
Weight loss percentage: 17.6
Weight loss percentage: 12
Weight loss percentage: 27.2
Weight loss percentage: 9.41
Medication monitoring failures: 15
Expired food items: 10
Census: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in medication error finding for leaving medications unattended in Resident #5's room. |
| Previous ADON Q | Assistant Director of Nursing | Reported medication error incident and confirmed policy on medication administration. |
| DON | Director of Nursing | Interviewed multiple times regarding weight monitoring, dialysis care, medication administration, infection control, and food safety. |
| RD | Registered Dietician | Interviewed regarding nutritional assessments, recommendations, and follow-up failures. |
| LPN M | Licensed Practical Nurse | Confirmed Resident #42 was not on fluid restriction. |
| RN N | Registered Nurse | Unable to locate dialysis communication book. |
| CNA Y | Certified Nurse Assistant | Observed failing to don proper PPE in Contact Isolation room. |
| CNA X | Certified Nurse Assistant | Observed handling food trays from Contact Isolation room without PPE. |
| WCC/IP | Wound Care Certified/Infection Preventionist | Interviewed regarding infection control practices and PPE use. |
| Administrator | Interviewed regarding food safety and infection control practices. | |
| Regional Director of Clinical Services | Conducted staff education on weight loss policy and participated in QAPI meetings. | |
| VP of Reimbursement | Vice-President | Participated in QAPI meetings regarding Immediate Jeopardy. |
Inspection Report
Routine
Census: 57
Deficiencies: 3
Date: Jan 9, 2020
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication administration, resident assessment after significant changes, and food safety and hygiene practices.
Findings
The facility was found deficient in ensuring a nurse remained with a resident during nebulizer treatment, completing a Significant Change Minimum Data Set (MDS) assessment for a resident referred to hospice, and maintaining sanitary food preparation conditions including proper hand hygiene and facial hair coverage among dietary staff.
Deficiencies (3)
Failed to ensure a nurse remained with a resident during inhalation treatment as required by facility policy.
Failed to complete a Significant Change Minimum Data Set (MDS) assessment for a resident referred to hospice services.
Failed to ensure food was stored, prepared, and served under sanitary conditions, including carbon build-up on stove and oven, and dietary staff failing to perform hand hygiene and having exposed facial hair.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 57
Census: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration deficiency for leaving resident during nebulizer treatment |
| Dietary Manager | Interviewed regarding food safety deficiencies and facial hair policy | |
| Registered Dietician | RD | Interviewed regarding hand hygiene expectations |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Feb 22, 2019
Visit Reason
The inspection was conducted based on complaints regarding failure to implement fall interventions, medication administration errors, and improper medication storage at Franklin Wellness and Rehabilitation Center.
Complaint Details
The visit was complaint-related due to allegations of failure to implement fall interventions, medication administration errors, and improper medication storage. The complaints were substantiated based on policy review, medical record review, observations, and interviews.
Findings
The facility failed to implement fall prevention interventions for Resident #30, failed to ensure correct placement of a PEG tube before medication administration for Resident #16, failed to administer the correct dose of medication resulting in a medication error, and failed to properly store medications during administration.
Deficiencies (5)
Failed to prevent accidents related to falls for Resident #30 when fall interventions were not implemented.
Failed to ensure Resident #30 was free from accident hazards by not implementing fall interventions.
Failed to ensure correct placement of the PEG tube before administering medication for Resident #16.
Failed to ensure residents were free from significant medication errors when LPN #1 failed to administer the correct dose of Tegretol to Resident #16.
Failed to ensure medications were properly stored when LPN #1 left medication unattended during administration.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication dose: 200
Medication flush volume: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Failed to check PEG tube placement, administered incorrect medication dose, and left medication unattended |
| Director of Nursing | DON | Interviewed regarding fall interventions, medication administration, and medication storage policies |
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